Health inspection·May 23, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman about resident transfers, for six of six residents reviewed for hospitalizations (Residents 1, 9, 14, 20, 55, and 71). Findings include: Nursing documentation for Resident 9 dated April 18, 2023, at 11:30 AM revealed the resident was transferred to the hospital after a fall. Nursing documentation for Resident 9 dated April 19, 2023, at 10:17 AM revealed that the resident was admitted to the hospital on [DATE], at 5:13 PM with a fracture of the ribs and right femur. Nursing documentation for Resident 20 dated February 10, 2023, at 3:35 AM revealed the resident was experiencing abdominal pain. Nursing documentation for Resident 20 dated February 10, 2023, at 3:53 AM revealed the resident was transferred to the Emergency Department via Emergency Medical Services. Nursing documentation for Resident 20 dated February 10, 2023, at 12:02 PM revealed the resident was admitted to the hospital based on imaging results. A clinical provider note for Resident 71 dated April 27, 2023, at 12:17 PM revealed an order was given to send the resident to the Emergency Department. The resident was experiencing tachycardia (fast heartrate), tachypnea (rapid breathing), and complaints of heartburn. Nursing documentation for Resident 71 dated April 28, 2023, at 10:09 AM revealed the resident was admitted to the hospital on [DATE], at 6:40 PM for lactic acidosis (a build-up of acid in the body). Further clinical record review for Residents 9, 20, and 71 revealed no evidence that the Office of the State LongTerm Care Ombudsman was notified as required about the transfers to the hospital. Clinical record review for Resident 14 revealed a progress note dated February 5, 2023, at 10:20 AM that indicated she was sent to the emergency room (ER) for evaluation and treatment related to having a left side facial droop and numbness and tingling on her left side. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 395101 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)